An area of erythema on the child's skin is being assessed by the nurse. The nurse presses down on the area, and the area becomes white. What term does the nurse document for this finding?
Blanching
Warmth
Redness
Nonblanching
The Correct Answer is A
Choice A reason: Blanching is the term that the nurse documents for this finding, because it describes the temporary whitening of the skin when pressure is applied. Blanching indicates that the blood vessels in the skin are constricted or compressed, and that the blood flow is reduced or interrupted. Blanching can be a normal response to cold, stress, or pressure, or it can be a sign of a problem, such as ischemia, infection, or inflammation.
Choice B reason: Warmth is not the term that the nurse documents for this finding, because it describes the increased temperature of the skin, not the color change. Warmth indicates that the blood vessels in the skin are dilated or expanded, and that the blood flow is increased or enhanced. Warmth can be a normal response to heat, exercise, or emotion, or it can be a sign of a problem, such as infection, inflammation, or allergy.
Choice C reason: Redness is not the term that the nurse documents for this finding, because it describes the original color of the skin, not the color change. Redness indicates that the blood vessels in the skin are dilated or expanded, and that the blood flow is increased or enhanced, as explained above. Redness can be a normal response to heat, exercise, or emotion, or it can be a sign of a problem, such as infection, inflammation, or allergy.
Choice D reason: Nonblanching is not the term that the nurse documents for this finding, because it describes the opposite of what the nurse observed. Nonblanching means that the skin does not turn white when pressure is applied, but rather remains red or purple. Nonblanching indicates that the blood vessels in the skin are damaged or ruptured, and that the blood has leaked into the surrounding tissues. Nonblanching can be a sign of a serious problem, such as bruising, bleeding, or necrosis.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Fistula is a complication of wound healing that is an abnormal passage that connects two body cavities or a cavity and the skin. Fistula can occur as a result of infection, inflammation, trauma, surgery, or congenital defect. Fistula can cause pain, bleeding, discharge, or leakage of fluids or gases from the affected organs or tissues. Fistula can also increase the risk of infection, obstruction, or perforation of the involved organs or tissues.
Choice B reason: Hemorrhage is not a complication of wound healing that is an abnormal passage that connects two body cavities or a cavity and the skin, but rather a complication of wound healing that is an excessive or uncontrolled bleeding from the wound site. Hemorrhage can occur as a result of trauma, surgery, infection, or coagulation disorder. Hemorrhage can cause pain, swelling, bruising, or shock at the wound site. Hemorrhage can also lead to blood loss, anemia, or hypovolemia.
Choice C reason: Infection is not a complication of wound healing that is an abnormal passage that connects two body cavities or a cavity and the skin, but rather a complication of wound healing that is an invasion and multiplication of microorganisms in the wound site. Infection can occur as a result of contamination, poor hygiene, or impaired immunity. Infection can cause pain, redness, warmth, swelling, or pus at the wound site. Infection can also trigger inflammation, fever, or systemic illness.
Choice D reason: Evisceration is not a complication of wound healing that is an abnormal passage that connects two body cavities or a cavity and the skin, but rather a complication of wound healing that is a protrusion of internal organs or tissues through the wound site. Evisceration can occur as a result of dehiscence, which is a separation or splitting open of the wound edges. Evisceration can cause pain, bleeding, or shock at the wound site. Evisceration can also expose the internal organs or tissues to injury, infection, or necrosis.
Correct Answer is A
Explanation
Choice A reason: Psoriasis is a skin abnormality that causes patches of thick, red skin with silvery scales, usually on the elbows, knees, scalp, lower back, or genitals. Psoriasis is a chronic, inflammatory, autoimmune condition that affects the life cycle of skin cells, causing them to build up rapidly on the surface of the skin. Psoriasis can cause itching, burning, pain, or bleeding.
Choice B reason: Rosacea is a skin abnormality that causes redness, flushing, swelling, or pimples, usually on the face, especially the cheeks, nose, chin, or forehead. Rosacea is a chronic, inflammatory, vascular condition that affects the blood vessels and sebaceous glands of the skin. Rosacea can cause sensitivity, stinging, or dryness.
Choice C reason: Scabies is a skin abnormality that causes small, red bumps, blisters, or burrows, usually on the hands, wrists, feet, ankles, or genitals. Scabies is a contagious, parasitic infection that is caused by tiny mites that burrow into the skin and lay eggs. Scabies can cause intense itching, especially at night.
Choice D reason: Stasis dermatitis is a skin abnormality that causes swelling, redness, scaling, or ulcers, usually on the lower legs or ankles. Stasis dermatitis is a chronic, inflammatory condition that results from poor blood circulation in the veins of the legs, causing fluid to leak into the surrounding tissues. Stasis dermatitis can cause pain, itching, or infection.
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